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ID/O/.a^ 3 : 3S3-/C/ 


AMCP 385-101 


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SAFETY DIGEST 








MAY 197 





# 




X*X;X;X*X*: 






HEADQUARTERS 

UNITED STATES ARMY MATERIEL COMMAND 

WASHINGTON, D C. 20315 


AMC PAMPHLET Number 385-101 


MAY 1971 


::•: 


The Safety Digest is an AMC Pamphlet prepared by the Safety Office, 
Headquarters, U. S. Army Materiel Command. Its purpose is to disseminate 
information which can materially influence and improve safety programs at 
all Command establishments. 

Articles are included to supplement technical knowledge as well as practical 
knowledge gained through experience. They provide a basis for the further 
refinement of safety measures already incorpotated in operating procedures 
and process layout. To achieve maximum effectiveness, the Safety Digest 
should be given widespread circulation at each AMC establishment. 

Articles appearing in the Safety Digest are unclassified and are not copy- 
righted. They may be reproduced as desired in order to bring pertinent 
accident prevention information to the attention of all employees. The Army 
Materiel Command Safety Digest should be given a credit line when articles 
are extracted. 

Unclassified material believed to be of interest or benefit to other establish- 
ments is welcqme for publication in the Safety Digest. Please send articles 
for review to: U. S. Army Materiel Command Field Safety Agency, Charles- 
town, Indiana. If possible, include pictures, charts, drawings, and illustrations 
that clarify and heighten interest in your presentation. 

(AMCSF) 


FOR THE COMMANDER: 
OFEICIAL: 



W. J. PHILLIPS 
Colonel, GS 

Chief, Administrative Office 
Special Distribution 1 


CHARLES T. HORNER, JR 
Major General, USA 
Chief of Staff 






IN THIS ISSUE 


FOREWORD 

IN THIS ISSUE 

FAULT TREE ANALYSIS AS AN AID TO IMPROVED PERFORMANCE 

LOU JEZEK RETIRES 

SAFETY MANAGEMENT AND STANDARDS 

BELIEFS ABOUT DANGER OF CARBON MONOXIDE ARE CHANGING 

EXTRAS THAT PAY OFF 

UPDATE THAT WEATHER COMPLETELY 

A PRO IS A PRO 

CURRENT EVENTS 

CHAIN SAW CUTS OPERATOR 

BROOM NO MATCH FOR BLASTING CAPS 

MISSTEP YIELDS HOT FOOT 

TABLE SAW CATCHES THUMB 

DRAGLINE DISCHARGE DAMAGES DUMP TRUCK 

SPLASHING ACID LEAVES ITS MARK 

WISE OWL EXHIBIT 

US ARMY ABERDEEN RESEARCH AND DEVELOPMENT CENTER EARNS 

AMC AWARD OF HONOR FOR SAFETY 

CORNHUSKER ARMY AMMUNITION PLANT OPERATING CONTRACTOR WINS 

NSC AWARD OF MERIT 

EXPLOSIVES SAFETY 

APE 1136, PROPELLANT WEIGHING SYSTEM 

THE ELUSIVE SIDE OF PROGRESS 

REFERENCE PUBLICATIONS 

US ARMY ARMOR AND ENGINEER BOARD RECEIVES AMC AWARD OF 

MERIT FOR SAFETY 

JEFFERSON PROVING GROUND WINS AMC AWARD OF HONOR FOR 

SAFETY 

DID YOU TAKE A GOOD LOOK IN YOUR MIRROR TODAY? 

DO YOU KNOW? 

MOBILITY EOUIPMENT R&D CENTER WINS NATIONAL SAFETY COUNCIL 

AWARD OF HONOR 

LIMA ARMY MODIFICATION CENTER WINS SEVENTH CONSECUTIVE 

AMC AWARD OF MERIT 

DANGEROUS CHEMICAL REACTIONS 

WELL, DID YOU KNOW? 


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Digitized by the internet Archive 
in 2016 


https://archive.org/detaiis/amcsafetydigest1971 wash_1 


FAULT TREE ANALYSIS 
AS AN AID TO IMPROVED PERFORMANCE 


Part 1 

Basic Fault Tree Mathematics 


The purpose of this article is to describe one of the 
better known techniques of system safety analysis; i.e., 
the fault tree. Part 1 outlines the basic mathematics useful 
to an understanding of the fault tree technique, while Part 2 
will be oriented toward application of the Part 1 concepts. 

The discovery of the fault tree analysis (FTA) is 
generally attributed to H. A. Watson of the Bell Telephone 
Laboratories during the early 1960's. It was first used to 
successfully determine the probability of inadvertent launch 
of a Minuteman Missile, Since that time, several individuals 
and organizations have done a great deal of work toward 
adapting the technique to a variety of operations and projects. 
In fact, one of the distinct advantages of FTA is that it can 
be applied to virtually any item with beneficial results. 

There are diverse systems to which the technique has been 
applied. The following list presents both the system and the 
undesired event studied. These include: 

1. Home fire alarm ("fire with no alarm"), 

2. Liquid hydrogen system ("tank rupture"). 

3. Automobile seat belt ("no protection from seat 

belt" ) . 

4. Automotive engine ("engine failure to continue 
running normally"). 

5. Automotive engine ("failure in high voltage portion 
of system" ) . 

6. TNT flaker drum ("run oil"). 

7. Air compressor ("compressor system loss"). 

8. Hot water heater ("injury, death and/or property 

damage" ) . 


1 


The status of the technique is such that one company 
has been formed which uses high-speed computer simulations 
for evaluating fault trees, a particularly valuable method 
of analysis solution for large complex systems. 

Two points should be emphasized at this time. First, 
the above list indicates that the item or system which is 
being analyzed need not be "complex" in order for the technique 
to be useful. Second, although a great deal has been written 
concerning fault tree quantification (numerical evaluation) , 
one should always remember that much good information can be 
obtained from a strictly qualitative analysis. 

Let us now begin our study of the fault tree by briefly 
examining some of the concepts associated with a branch of 
mathematics known as set theory. 

One of the most basic notions in mathematics is that of 
a collection or group; i.e., a set of items: For example, 

a "set of wrenches", "a coin collection", "a herd of cattle" 
or "a flock of geese". The definition of a set can be thought 
of as a collection of objects with a common property. 

It is also possible for the elements of a set to be sets 
themselves; an example is a set consisting of all the batch- 
type TNT plants. Each TNT plant may be considered a set 
consisting of its separate operating units such as the mono, 
bi, tri, wash and nail houses. This is the concept of the 
subset . 


There are several other terms that will be referred to 
throughout the discussion and must therefore be defined at this 
time. These include: 

1. Universal Set . This is the set to which con- 
sideration is limited and is represented by either "I" or the 
number one (1). Some examples of this include the table of 
contents of a book and the agenda for a meeting. 

_ 2. Negation . The negation, or complement, "A*" or 

"A", of a set "A" contained in "I" is the set of all elements 
of "1" which do not belong to "A". 

3. Union. The union, "A U B" , of two subsets "A" 
and "B" of "I" is that subset which consists of those elements 
which belong to "A" or "B" or both. Informally, this operation 
may be thought of as "logical" addition. 


2 


4. Intersection . The intersection, "A fl B", of "A" 
and "B" is the subset of "I" which consists of all elements 
belonging simultaneously to both "A" and "B" . This operation 
may be thought of as "logical" multiplication. 

5. Empty Set. Sometimes referred to as the "null" 
set (symbolized by ''0*' or the number zero (0)), this quantity, 
peculiar to logical mathematics, contains ^ elements. 

In order to better visualize this concept, the Venn diagram 
can be used to depict the universal set and some of its subsets. 
The universal set is represented by a rectangular area of any 
size, while subsets within this universe are represented by 
circular areas. One, two, three or more circles may be used 
in these diagrams. Also, if a certain set is only partially 
in the universal set, it may be represented by a circular area, 
part of which is in the rectangle. 

Figure 1 depicts the Venn diagrams representing the basic 
operations previously discussed. 

As an example of how the Venn diagram with one circle may 
be used, let us consider the following example which makes use 
of the "negation" diagram shown in Figure 1. 

With respect to that diagram, let us define the following 
areas . Let 

I = the set of all automobiles in the world, and let 

A = the set of all red automobiles in the world. Then 

A* = the set of all not-red automobiles in the world. 

Even though the following is a very simple diagram, it 

does point out that every area on the Venn diagram does have 
some "real", or "physical", significance. This is true no 
matter how many circles, or sets, are represented on a given 
Venn diagram. 

An important point to note at this time is the significance 
of negation, union and intersection. This can best be summed 
up by remembering that : 

1. Negation implies the word "NOT". 

2. Union implies the word "OR". 

3. Intersection implies the word "AND". 


3 



4 


The above word associations are most important as they 
will be used extensively in conjunction with the development 
of the fault tree itself. 

Let us now apply the above concepts to another part of 
mathematics known as Boolean algebra. 

A discussion of Boolean algebra might well be begun by 
asking the question, "What is an algebra?" An algebra is 
nothing more than a collection of symbols with a set of rules 
which govern their manipulation. 

There are several types of algebras, including: 

1. Ordinary -- symbols represent numbers. 

2. Vector -- symbols represent vectors (a quantity 
having both magnitude and direction). 

3. Boolean -- symbols represent the operations of 
formal logic. 

As might be expected, the rules of operation for ordinary 
vector and Boolean algebra are quite different. 

Some of the more important rules and laws of Boolean algebra 
are presented as Figure 2. As can be seen from the figure, the 
operations of Boolean algebra include those previously discussed 
in conjunction with set theory; i.e., negation, union and 
intersection. Their main use is in the area of reference to 
aid in simplification, combination and rearrangement of other 
Boolean expressions. 

For example, it will be shown in Part 2 that it is possible 
to develop a Boolean expression after the fault tree has been 
constructed. By using the information given in Figure 2, it 
may be possible to then simplify the original equation. 
Specifically, let us assume that the following expression has 
been developed from a certain "tree". 

C = A U (A n (BUA*)) U (A' n B). (1) 

By slightly modifying (4a) and (6a) of Figure 2, one gets 

A n (BUA') = (A n B) U (AHA’) (2) 


and 


AnA' = 0. 


(3) 


5 


1. Commutative Law: 


a. X0Y = YnX; b. (XUY) = YUX 

2. Associative Law: 

a. Xn(YDZ) = (XDY)OZ; b. XU(YUZ) = (XUY)UZ 

3. Idempotent Law: 

a. Xf)X = X; b. XUX = X 

4. Distributive Law: 

a. XD(YUZ) = (XOY) U (XOZ); b. XU(Y/3 Z) = (XUY) /l(XUZ) 

5. Law of Absorption: 

a. X/0(XUY) = X; b. XU(X/)Y) = X 

6. Complementation: 

a. XDX' = 0; b. XUX' = I; c. (X')' = X. 

7. DeMorgan's Theorem: 

a. (XOY)' = X'UY'; b. (XUY)' = X'/^Y' 

8. Simplification: 

a. XU (X'n Y) = XUY; b. X'zO(XUY') = X'/OY' = (XUY)' 


Figure 2. Selected Operations of Boolean Algebra. 


6 


Substitution of (2) and (3) into (1) gives 


C = A U (A n B) U (0) U (A' n B), 


( 4 ) 


or 


C = A U (A n B) U (A' n B) . (5) 

Writing (5b), Figure 2, as 

A U (A n B) = A, (6) 

and substituting into (5) gives 

C = A U (A' n B) . (7) 

Again, returning to Figure 2 and rewriting (8a) as 

A U (A* fl B) = AUB (8) 

and substituting into (7) gives the final result, or 

C = AUB. (9) 

The above analysis proposes then that (1) and (9) are the 
equation, with (9) being a simplified version. One should 
remember that this is only an example chosen to show a technique 
and concept and may therefore not be entirely characteristic of 
the type of expression encountered in actual practice. 

This discussion has only covered some of the highlights of 
set theory and Boolean algebra, and for those who wish to go 
into more detail in these areas, it is recommended that the 
references listed at the end of this article be consulted. 

Finally, it should be noted that in Part 2 (an article 
for the next edition) , the ideas developed above will be applied 
to the construction of fault trees for specific systems. In 
so doing, it will be necessary to discuss fault tree symbology, 
generation of the tree itself, derivation of the Boolean 
expression and quantification methods. 


SELECTED REFERENCES: 

1. Baker, C.C.T.: "Introduction to Mathematics", Arco Publishing 

Co., Inc., New York, N. Y., 1966. 1 ed . 


7 


2. Beizer, B. and S. W. Leilholz : "Engineering Applications 

of Boolean Algebra", Electrical Mf g . , May-October 1958. 

3. Hohn , E. E.: "Applied Boolean Algebra", The Macmillan Co., 

New York, N.Y., 1966, 2 ed . 

4. Zenna, P. W. and R. L. Johnson: "Elements of Set Theory", 

Allyn and Bacon, Inc., Boston, Mass., 1962, 1 ed . 


LOU JEZEK RETIRES 

LOU JEZEK, Safety Engineer, Headquarters, AMC Safety Office, 
retired 29 January 1971, after 35 years of Government service. 
Lou's lengthy career began at Curtis Bay Ordnance Depot in 1930. 

In 1942, he transferred to the Office, Chief of Ordnance, where 
he was employed until his military service began in 1943 . From 
1943 through 1946, Lou served as an Army EOD specialist at 
Aberdeen Proving Ground, Leyte, Luzon and Japan. 

After his discharge from the Army, Lou was employed as a 
safety engineer with the Office, Chief of Ordnance until August 
1962, and from then until his retirement, with the Army Materiel 
Command . 

At his retirement party, which was attended by approximately 
85 of his friends, including LTG Joseph M. Heiser, Jr. , DCSLOG, 

Lou received the DA Certificate of Achievement (presented by 
LTG Heiser, DCSLOG), the AMC Certificate of Achievement (presented 
by Mr. Landon Feazell, Chief, AMC Safety Office), and the AMC 
Certificate of Recognition (presented by Mr. Fred M. Bishoff, 

Chief of Safety, US Postal Service, and former Chief,-' AMC Safety 
Office ) . 


8 


SAFETY MANAGEMENT AND STANDARDS 


H. J. Bigham, Safety Supervisor 
Hercules Incorporated 
Sunflower Army Ammunition Plant 


The role of standardization in safety expanded with the 
rise of modern business, and its importance was enhanced by 
the spread of scientific management. During World Wars I and 
II, the Federal Government contributed to the standardization 
movement when its procurement agencies specified standards 
for the commodities and materials to be purchased. These 
standards were designed to conserve materials, plant capacity 
and manpower. The movement toward standardization has 
continued to grow in the industrial sector and to receive 
organized national and international attention. 

Trade associations and technical societies, through the 
participation of members, have established many standards used 
in industry. One important body in the standardization movement 
is the National Bureau of Standards, which, at the request 
of private industry, tests and establishes working standards for 
any item, maintains the standards of weights and measures, and 
develops testing methods and apparatus. Another is the American 
National Standards Institute (ANSU which is composed of a number 
of engineering societies, industrial trade associations, and 
Federal Departments. It coordinates the work of committees 
representing member groups, approves and publishes industrial 
and engineering standards and safety codes, and represents 
American industry in its efforts toward international 
standardization . 

Standardization is an important function of safety 
management because it makes possible the control of safety 
activities at a definite level of performance and quality. 

Safety operations improve and costs decline when activities 
and practices will conform and be appraisable. Safety is a 
primary field in which standards can beneficially be established. 

It is impossible to operate any program without specific guidelines. 
Safety standards are the guidelines for the operation of a 
safety program. 

General standards have been established by Federal, State 
and local governments. Specific standards have been established 
by the Department of the Army and the Army Materiel Command and 
applicable requirements must be followed by all AMC installations. 
Other standards have been established by corporate management, 
national testing laboratories and other agencies. 


9 


An important aid to safety program administration is 
a library of reference material including safety standards, 
readily available to safety and operating personnel. A 
standards training program will insure that supervision under- 
stands what standards are, what they are intended to do and 
how they are to be used. It is important that current changes 
or additions to standards are communicated to plant management 
and supervision. 


USE OF STANDARDS IN 
SAFETY PROBLEM SOLVING 



A timely handout is used at Sunflower Army Ammunition 
Plant to aid in understanding the many standards used in 
implementing our safety program (see Figure 1.). This handout 
is used as part of our safety training material for safety 
personnel and is modified in programs designed for engineers. 

It has been a most useful tool in explaining and understanding the 
complexity of the standards program. 

If safety is to keep pace with other management techniques, 
safety personnel must keep abreast of the changes that are 
engulf«ing us in the standards area. The standards philosophy 
must be integrated into all levels of our management educational 
system . 


10 


BELIEFS ABOUT DANGER OF 
CARBON MONOXIDE ARE CHANGING 


COL F. C. Leitnaker 
Surgeon, AMC 


To introduce this discussion, I would like to relate a 
personal incident in which a chain of circumstances may have 
saved two lives. I was unexpectedly home the other evening 
because my plans to go to a local Pizza house and listen to 
the Dixieland Band were changed by a daughter who fixed Pizza 
for supper and drafted me to taxi her to a friend's house 
afterwards. While awaiting her pick-up call, I was reading and 
contemplating my martyrdom at home when the phone rang. It was 
my coed daughter in Kansas, half a continent away. 

"Daddy", she said, "I need some medical advice. Two of my 
friends are sick and they’ve just been given a shot for food 
poisoning here in the emergency room and told to go home. This 
is the third or fourth time they've been sick like this. Would 
you tell me what it sounds like to you?" 

"Sure," I said. "What are their symptoms?" 

"Well they are nauseated and Bill vomited but they have this 
terrible headache and ringing in their ears and they're awfully 
weak. Everytime they've gotten sick it's in their apartment. 

Does this sound like anything to you?" 

"It sure does," I said, ''carbon monoxide. How do they heat 
their apartment?" 

"With gas." 

"Furnace, stove or what?" 

"A heater that they light with a match." 

"Is it connected to a chimney or flue?" 

"No. " 

"That's it," I said. "I'm 95% sure. Get hold of a doctor 
again and tell him what you told me and that I think it's carbon 
monoxide. And don't let them go back in there with that heater 
on. Air out the place." 


11 


Another doctor then saw them and agreed with my telephonic 
diagnosis, but by this time the patients were much better and 
no treatment was required. 

Carbon monoxide (CO) has long been known to be a potential 
killer. (See TB MED 269 for a recent and authorative conventional 
discussion.) Until fairly recently, however, the consensus has 
been that low levels in the environment were relatively harmless. 
Until 1965, an occupational exposure to CO in an air concentration 
of 100 parts per million (ppm) for 40 hours per week was con- 
sidered acceptable and harmless (American Conference of Governmental 
Industrial Hygienist). This figure was challenged on the basis 
of recent studies and was reduced to 50 ppm tentatively in 1965 
and officially in 1967. 

CO acts primarily by binding to hemoglobin as does oxygen. 
However, the hemoglobin bound by CO becomes unavailable to bind 
oxygen. Furthermore, CO binds to hemoglobin much more tightly 
than does oxygen and is only gradually released. Although half 
of the CO so bound may be released in two houfs (TB MED 269 says 
six hours), it requires another two hours for half of the re- 
mainder to be released and so forth. In other words, half is 
released in two hours, 3/4ths is released in four hours, 7/8ths 
is released in six hours, etc. 

Obviously, if enough of the body hemoglobin is bound with 
CO, the blood will be unable to carry enough oxygen to the 
various organs of the body and symptoms of oxygen lack will occur. 
Death results when approximately 60% or more of the hemoglobin 
is so bound. 

There is even a more serious effect of CO which results 
from a similar binding with substances in the tissues. Such 
binding prevents the cells from utilizing the oxygen delivered 
to them by the blood. 

Recent evidence indicates that amounts of CO in the blood 
too small to produce symptoms recognized by the individual may 
result in subtle but, by very sensitive techniques, measurable 
decrements in function. Are these subtle functional decrements 
significant? Usually not, but in an emergency situation where 
optimal functioning is required to prevent or minimize an 
accident, a small decrement of function can be disastrous. 

There is, to date, little direct evidence that low CO levels in 
the blood are, in fact, a factor in accidents. There is, however, 
ample indirect evidence, based on studies of other substances 


12 


which impair function (primarily alcohol), to strongly suspect 
this is true when combined with laboratory studies showing 
decrement of function with CO in the blood. Some studies 
(although not universally accepted) show such decrement when 
2% of the body hemoglobin is combined with CO. 

Another belief which is changing is that there are no 
health effects from long term (low level) continuous or frequently 
repeated exposures to CO. Recent studies suggest, on the contrary, 
that such exposure may be an important factor in the development 
of heart disease. 

The sources of CO in the environment are multitudinous, 
but those of major importance to the largest numbers of people, 
include the internal combustion engine (primarily motorcars) 
and tobacco smoke. There are still idiots among us who run 
gasoline engines in confined spaces with personnel present. But 
you don't have to be stupid to develop significant levels of CO 
in your blood stream from auto engines. Imperfect exhaust 
systems which allow CO to enter the passenger compartment of 
cars are common. Serious poisoning and even death occasionally 
result, but unrecognized poisoning is certainly very common. If 
you follow another car too closely in traffic, its exhaust fumes 
may go directly in your ventilation intake. Four feet has been 
considered too close. Perhaps 10 or more should be specified. 

It is well known that heavy cigarette smokers may have 10% 
or even more of their hemoglobin combined with CO. This level 
has been estimated to require a 40% increase of organ profusion 
and a reserve capability of several hundred percent, this effect 
usually produces no symptoms of which the patient is aware. 

But it can become critical in case of a heart attack or brain 
stroke in which maximum usable oxygen may make the difference 
between life and death. The athletic handicap of heavy smoking 
has been long recognized and is a matter of common knowledge 
but has only recently been adequately explained. The correlation 
between hardening of the arteries (which may produce a variety 
of manifestation of poor circulation to the heart, legs, brain 
and kidneys) and smoking is largely explained by CO according 
to a number of medical researchers. Further work is required to 
substantiate this to the satisfaction of all physicians. Smoking 
low-tar, low-nicotine cigarettes may not give us the hazard 
reduction we assumed since the CO in all cigarette smoke is the 
same even when lettuce leaves are substituted for tobacco. 

Little attention has been given to the combined effect of 
CO and other substances, for example, alcohol. It has yet to be 
documented but reasonable to assume that a given amount of alcohol 
would produce a greater decrement of function when, say, 10% of 
CO combined hemoglobin is in the blood. 


13 


At a time when the public is being bombarded with all 
kinds of things -- old and new -- to worry about, I hesitate 
to add my voice to the clamor. I shan’t imply that CO should 
be your major concern in life or that the probability is high 
it will kill you tomorrow if you are not careful, but I would 
like you to realize that it is a greater hazard than you have 
previously been lead to believe and may well be a greater hazard 
than a number of hazards you attempt to guard against. There 
are, of course, positive things you can and should do: 

(1) Quit smoking if you do and can* 

(2) Keep your exhaust system in good condition. 

(3) Take positive action if you can smell exhaust fumes 
inside your car. CO is oderless but the other fume ingredients 
are not. Get the car fixed or junk it and keep the window open 
in the meantime. 

(4) Leaving a window cracked as you drive, even if your 
exhaust system is in good condition and your car body is tight, 
is a good rule for safety. 

(5) Don't follow other cars closer than 10 feet any oftener 
than necessary. 

(6) Never operate an internal combustion engine in an 
unventilated space where people are present. 

(7) Never operate a fuel burning stove or heater in an 
inclosed space without a chimney or flue. 

(8) Obtain and read a copy of TB MED 269 for a more complete 
treatment of this important subject. 


EXTRAS THAT PAY OFF 


LTC L. H. Jaquay 
Aviation Office, US^AEPG 


The end of the normal duty day was fast approaching as 
the Army U-4 entered the traffic pattern for landing. Winds 
were strong and gusty, and typical for the time of year. 

The pilot completed a normal landing but during landing roll, 
the main landing gear collapsed, dropping the aircraft to its 
belly, causing skin and bulkhead damage. Thoughts of "What 
went wrong? Everything I did was according to the book" 
flashed through the pilot’s mind as he instinctively reached 
for switches and levers. The pilot was correct, he had followed 
the book when he accomplished his preflight inspection; he was 
right in procedures he followed during flight; and he completed 
the proper sequences during his landing approach. Yet he and 
the aircraft became an accident statistic. 

Let’s look at the follow-up. The accident investigation 
was completed with several maintenance deficiencies noted: the 

micro switch, which relays a safe landing gear indication to 
the cockpit display, was improperly adjusted, giving the pilot 
a safe condition when the landing gear was, in fact, not safe. 

But this by itself could not have caused the landing gear to 
collapse. The investigators continued looking. A small, not- 
so-obvious lock nut was found to have backed off from its locked 
position causing the landing gear retracting arm adjustment to 
change and prevented the bungee cords from positioning the 
landing-gear-drag-brace to an "over-center", positive lock 
position. Although small and not-so-obvious , the lock nut 
contributed to a series of events that resulted in the accident. 

This story must have a moral to match its title "Extras 
That Pay Off" . The pilot performed his preflight "by the book" 
but the book did not require him to inspect that small, not-so- 
obvious lock nut for security. Instead ,it calls for a general 
survey of the landing gear, not an inspection of specific items. 

While all operators of Army aircraft and those who main- 
tain them should follow the book, they should go one step 
further, and check not-so-obvious items. Instructor pilots 
and maintenance inspectors must pass on their knowledge about 
not-so-obvious items they’ve learned by experience or through error 


15 



Pencil points out the ”Not-so-obvious" lock nut which 
had loosened on the actuating rod. Mechanism is 
located on landing gear assembly. 

By accomplishing the not-required , yet significant extra 
checks, you can prevent accidents like these from reaching 
the tally sheet. 


EDITOR'S NOTE: Over the years, many valuable additions have 

been made to policy guidance, as well as 
regulations, by personnel most closely associated 
with the materiel. Recommended changes to 
procedures may have prevented the above accident. 
In concert with the above theme, make that little 
bit extra really pay off. Initiate a Recommended 
Change to Publications (DA Form 2028) to correct 
those errors or deficiencies obvious to you - 
but not-so-obvious to others. 


l6 


UPDATE THAT WEATHER COMPLETELY 


MAJ Robert J. Moxley 
Avn Safety Officer, USAECOM 


Each and every aviator has, at some time, had his flight 
delayed. If it wasn't because our passengers were late, it 
may have been due to minor maintenance difficulties or some 
procedural fault of our own. How did we update our weather 
briefing? Be honest with yourself. Didn't you sometimes just 
call the tower and ask tower personnel to "call weather and get 
me a new void time" - I have. Peeling that airplane off your 
backside and walking into weather for a new briefing is probably 
one of the most difficult maneuvers in aviation, but it can be 
well worth the effort and inconvenience. 

This past winter I watched the crew of a VIP mission air- 
craft preparing for a departure from home base. Weather all 
along the eastern part of the country was wet and windy. Both 
the point of departure and the destination of this flight was 
near the east coast and the weather was bad. The pilot received 
his weather briefing and completed the DD 175-1. Existing 
weather at the destination was reported as 400 feet broken, 900 
overcast, and 3 miles visibility with fog. Forecast for arrival 
was 1,000 feet overcast and 10 miles visibility. The alternate 
airfield, also on the east coast, had existing weather of 300 
feet overcast, and 2 miles light rain and fog. The alternate 
forecast was for 1,500 scattered, 6,000 broken, and 6 miles 
visibility with haze. Not a thing wrong with that terminal data; 

I could even "hack" that. 

Admittedly the en route weather would_ prevent Army aircraft 
from flying. The weather briefing called for moderate icing 
with occasional severe clear ice; however, this particular crew 
was flying a big machine with four fans and heated wings. 

With hot coffee on board, the flight plan filed, and the 
aircraft pref-lighted and warmed up, the crew now had nothing to 
do but wait for their passenger. Then came that telephone call 
with the news that their passenger would be late. No problem - 
"just call weather for an update." When I listened to the 
weather forecaster as our flight dispatcher copied the new 
weather, I couldn't believe he was talking about the same 
destination. In just 45 minutes, the existing weather had dete- 
riorated to 200 feet broken, 300 overcast, and 1/2 mile visibility 
with light rain and fog. The new forecast was for 200 feet overcast 
1/2 to 1 mile visibility. The alternate was still good. 


17 


Now let us stop the story and look at what we have. First, 
the destination weather had gotten worse and the forecast was 
for worse weather than had originally been forecasted - but it 
was still adequate. Secondly, the alternate was forecasted to 
remain above minimums . I have seen many an aviator accept a 
weather update like this without question and "punch on through". 

This crew was an experienced and Weatherwise one. With the 
destination forecast at the absolute minimum and the alternate 
now looking very much like it might be needed, they wanted a more 
detailed update to their weather. More particularly, they wanted 
to know more about the en route weather from the destination to 
the alternate. It was some spicy weather; half inch hail stones, 
thunderstorms, and tornadoes. A new alternate was selected. The 
nearest alternate that could be reached flying away from the 
severe weather was in the midwest. They could fly that far with 
no problem. 

Now change our story just a little. Make it a flight in a 
U-8 or U-21 and delete the occasional severe ice originally 
forecasted en route. The original destination and alternate were 
within range of these two aircraft. How easy it would have been 
to accept a quick update of the weather and depart feeling secure 
because of the adequate alternate. A missed approach at destina- 
tion would very likely have resulted in a tragedy. 

Never be satisfied with a quick weather update. Be a 
professional, treat each weather briefing as if it were a new 
one and get the most out of it. 


18 


A PRO IS A PRO 


Aviation Branch 
US Army Missile Command 

If you have done any instrument flying at all , you 
can surely recall an instance when the calm sure voice 
of a controller saying "Roger, Army 12345, this is XXXX 
Center..." was just about the most welcome sound imagin- 
able . 


By the same token, you can probably remember a pilot 
(yourself?) taking his frustrations out on a controller 
when he failed to respond to the first call or told the 
pilot to "hold, pending further clearance". 

Instrument flying is a time of prolonged concentra- 
tion. If our cross check is a little rusty and we’re 
chasing heading, airspeed and altitude all over the sky 
while trying to retune radios or revise an estimate , it " s 
just pc-ssible that we may feel the added pressures of 
frustration and mild panic and become something other 
than our "sweet lovable self". 

Now our copilot probably knows us pretty well and 
if we fly off the handle with him, we can apologize later, 
but how about the controller? 

Air traffic control is a trying and tedious business, 
particularly in high density areas. The pressures in- 
volved have been the basis for more than one novel, movie 
or TV story. In spite of the fact that controllers are 
carefully selected and well trained, they are, after all, 
still human and must at times be tempted to take care of 
the "nice guys" first. 

When we stop to think of it, pilots have only one 
aircraft to worry about. A missed or late radio call 
or fudging on an estimate ("Just one minute more!") may 
seem insignificant, but it can, on occasion, cause real 
and immediate concern to both pilots and controllers. 

At times like these, the "pucker" and "yell" factors 
increase at an extremely fast pace. 

So what’s the point of this discussion? Simply this- 
the voice on the other end of our radio' channel isn’t a 
machine its someone trying hard to do a job that is im- 
portant to us. Courtesy and consideration for his pro- 
blems won’t cost us much but they can be a pretty good 
indication that a professional is on our end. Are you 
a Pro? 


19 



CHAIN SAW CUTS OPERATOR 


Four contractor employees were assigned to perform tree 
felling and brush clearing operations in a wooded area remote 
to their installation. Using a gasoline -powered chain saw, 
one employee was trimming branches from a felled 30-foot pin 
oak tree. Working from ground level, he trimmed with the 
angle of the saw blade slightly below his belt line. 

During this limbing operation, the chain saw suddenly 
kicked back in an upward direction, striking the operator on 
the left side of his face. He suffered severe faciad. lac- 
erations and a severed sinus bone. 

The specific act and/or condition which prompted the chain 
saw to kick back was not ascertained. The saw was inspected 
and was found to be sharp and in proper working condition. A 
possible contributing factor was that the operator did not have 
a firm grip on the saw handle. 

In order to preclude the occurrence of similar accidents, 
the installation has implemented the following corrective actions 

1. All applicable employees have received refresher 
instruction in the safe and proper operation of chain saws. 

2 . The chain saw being used at the time of the 
accident was equipped with a 24-inch blade. For future limbing 
operations, chain saws with 12-inch blades will be used. It is 
felt that the shorter blade will provide the operator with 
more control. 


20 


BROOM NO MATCH FOR BLASTING CAPS 


Two civilian employees were processing .45 calibre ball 
ammunition in a small arms deactivation furnace (APE NO. 

1009M4) for the purpose of metal recovery. The operational 
layout consisted of a conveyor passing through an opening in 
a 12-inch reinforced concrete wall to a hopper which fed the 
rotary deactivation furnace. 

Earlier in the shift, the operators had conveyed approx- 
imately 1,000 non-electric blasting caps into the furnace. 
Although the destruction of such items in the furnace was not 
authorized, the operation had proceeded without incident. 

The operators had placed .45 calibre ball ammunition 
(in metal boxes) onto the conveyor, for approximately 15 
minutes when they decided to enter the furnace room to inspect 
the fire. While surveying the equipment, the men noticed that 
some of the boxes were lodged in the feed hopper. In an effort 
to free these boxes, one worker used a broom as a probe. 

Suddenly an explosion occurred which dismembered the worker's 
lower left arm and hand. The second operator was not injured. 

Physical evidence noted during the investigation of the 
explosion indicated that some blasting caps had also lodged in 
the feed hopper. Impact of the broom against the blasting caps 
was considered to be the probable cause of initiation. Disregard 
of the approved standing operating procedure by the operators 
was the underlying action which prompted the accident. 

Immediate corrective action taken by the installation 
centered on specialized job training for supervisors and 
operating personnel. This instruction included actual demon- 
strations of the equipment in proper operation, and detailed 
discussion of applicable operating procedures. 

MISSTEP YIELDS HOTFOOT 


An electrical fire had been reported to the Post Engineer; 
however, upon arriving at the scene, personnel determined that 
the fire was nothing more than a steam leak. A power plant 
operator and an electrician entered the room and moved toward 
the utility tunnel. Visibility in the room and tunnel was 
impaired due to the steam. Using a common two D-cell flashlight, 
the men proceeded slowly into the tunnel. 


21 


Approximately 10 feet within the tunnel, the electrician 
noticed that the sump pump was not functioning. He pulled 
the service plug from the wall receptacle and began to check 
the receptacle with a voltage tester. As the other worker 
moved toward the electrician to aim the flashlight on the 
receptacle, he stepped in the sump pump opening. This two- 
foot hole was filled with hot water caused by dripping steam 
condensate. The employee suffered second and third degree 
burns on his right ankle and foot. 

Investigation of this accident revealed that the sump pump 
had been plugged into the lighting circuit. When the pump motor 
shorted, the lighting circuit failed. No special portable 
lights were available to penetrate the fog-like atmosphere. The 
poor visibility increased the pre-existing hazard potential 
of the unguarded floor opening. 

To prevent similar accidents, the installation applied 
the following corrective actions: 

1. An iron grate platform was installed over the 
sump opening. 

2. The sump pump motor will be placed on a separate 

circuit . 

3 . A more frequent preventive maintenance schedule 
has been established for the sump pump. 


TABLE SAW CATCHES THUMB 


An enlisted man was assigned to the installation carpenter 
shop. During the course of his work, he began to cut an 8 -foot 
length of plywood on a table saw. Another worker was close by; 
however, the EM did not ask for assistance. 

Shortly after beginning his cut, the EM was distracted by 
the sound of a falling object to his rear. Although his atten- 
tion was divided only momentarily, he physically lost control 
of the plywood. In an effort to recover, he somehow thrust 
his hand into the moving saw blade. The EM suffered a partial 
amputation of his left thumb. 


22 


It was concluded that pressure in the form of binding 
made it extremely difficult for the saw operator to regain 
control of his stock. This blade/stock binding was attributed 
to the portion of plywood hanging off the table after having 
been cut (approximately five feet). 

To prevent similar accidents, the following instructions 
were reiterated: 

1. Personnel operating table saws will not turn 
their backs to the saw when stock is being cut. 

2 • _ Operators must be constantlv aware of and take 
all precautions against placing their hands in the proximity 

of the sawblade. 

3. Take-away men will render assistance to table saw 
operators when lengthy stock is being cut. 

DRAGLINE DISCHARGE DAMAGES DUMP TRUCK 

A contractor maintenance crew was removing silt from a 
lake bed. Although the lake had been drained during the summer, 
the silt had remained in a wet state. 

The silt removal operation had progressed without incident 
through the utilization of a crane equipped with a dragline 
bucket, transferring the silt from the lake bed into 5-ton 


The crane operator swung the loaded 
bucket over the dump truck bed , and 
tilted the bucket to discharge its 
contents. The silt did not discharge 
as expected. Before the operator could 
gain control of the swinging bucket, 
the load of silt catapulted from the 
bucket onto the cab protector, wind- 
shield and hood of the truck. Damage 
to the vehicle as shown in photo, was 
approximately $500.00. There were no 
injuries. (The truck driver had re- 
treated a safe distance after posi- 
tioning the truck for loading.) 



23 


Investigation of the accident lead to the conclusion 
that the silt was partially frozen, a condition which possibly 
caused it to hold in the bucket for an instant. Extremely 
cold weather was prevalent during this operation. 

The use of dragline equipped cranes for this type of 
work was discontinued as well as for similar types of jobs. 

All heavy equipment operators were instructed as to the hazards 
of wet /partially frozen silt removal. 


SPLASHING ACID LEAVES ITS MARK 


A contractor employee was operating a gas annealing 
furnace in a small arms ammunition manufacturing building. 
During the course of his duties, the worker noted excessive 
vibration in a steam line, the valve of which was located 
directly in front of an acid rinse vat. While closing the 
steam valve, the operator was sprayed with acid. He suffered 
disabling acid burns on his neck, chest, right arm and right 
upper leg. 

The acid rinse vat contained a 3-5% solution by volume 
of sulfuric acid. Extensive investigatory testing indicated 
that such concentrations of acid could not have produced the 
degree of material damage as had been incurred by the injured's 
clothing. It was determined that the acid source probably was 
the one gallon tank adjacent to the rinse vat. Subject tank 
contained 93% sulfuric acid. It was concluded that the 
employee, while closing the steam valve, had come into contact 
with the supply tank causing the 93% acid to spray from the 
fill orifice. Close inspection of the supply tank also re- 
vealed that its support brackets were eroded, a condition which 
reduced its stability. 

The installation implemented the following actions to 
preclude the occurrence of similar incidents : 

1. All acid supply tanks and support brackets will 
be inspected. Necessary repairs will be made. 

2. The acid supply tank will remain empty at all 
times except when acid additions to the rinse vat are required. 
(The acid supply tank is filled when necessary by a hand- 
operated pressure line from a carboy.) 

3. The accident was publicized throughout the 
installation . 


2k 


WISE OWL EXHIBIT 


W. E. Sass, Safety Engineer 
Mason 8 Hanger - Silas Mason Co., Inc. 
Cornhusker Army Ammunition Plant 


How valuable is an eye protection program? Is it really 
worth the chips? Questions like these really don't deserve 
an answer. But we in Safety must be aware of our dollars. 

We have to make monetary evaluations. 

Close your eyes for a moment. Would you want to walk 
the face of this earth in "that" darkness? Could you ask 
anyone to? Then when the situation arises, we must afford 
eye protection, no matter what the cost. 

Are there any benefits? We think so. We now have four 
employees who are members of the Wise Owl Club of America, an 
organization dedicated to the preservation of sight. If we 
simply compute the potential cost of these accidents against 
the cost of our eye protection program, we feel we're money 
ahead. Yes, we're happy about our employee membership in the 
Wise Owl Club. It means we have employees with broken lenses, 
and not sightless eyes. 

Our Safety Director suggested we display the broken safety 
glasses as a reminder to all personnel of the value of eye 
protection. A few ideas began to churn in my mind., I 
remembered seeing a poster or display that depicted various 
articles of eye protection. The top portion being two eyes, 
which were lighted and flashed "off" and "on". The words 
"KEEP 'EM BLINKING" were printed across the top. The "KEEP 'EM 
BLINKING" theme, tied in with our Wise Owl Club exhibit idea, 
sounded good . 



25 




The display features the lighted blinking eyes. We 
titled it the "Wise Owl Club Exhibit". The damaged lenses 
and safety glasses were mounted as bulletin board type inserts. 
The items which had broken the lenses were also mounted, with 
an arrow pointing to the specific item. See Photos 1 and 2. 
Also, pictures of members, their membership certificates, and 
our own Safety Director’s Safety Memo-Gram tell the story of 
each accident. 

The display is mobile and is moved to various strategic 
locations throughout the plant. To date, the comments and 
interest indicate the message is getting through loud and clear. 


US ARMY ABERDEEN RESEARCH AND DEVELOPMENT CENTER 
EARNS AMC AWARD OF HONOR FOR SAFETY 

The US Army Aberdeen Research 
and Development Center (ARDC) has 
received an AMC Award of Honor for 
Safety for FY 1970. Dr. R. B. Dillway 
(left). Deputy for Laboratories, 

US Army Materiel Command, is shown 
presenting the award plaque to 
COL Howard C. Metzler, Commanding 
Officer, and Mr. H. G. Buchanan, 

Safety Director, ARDC. 

• •». A A 

» 

CORNHUSKER ARMY AMMUNITION PLANT OPERATING CONTRACTOR 

WINS NSC AWARD OF MERIT 

Mason S Hanger - Silas Mason 
Co,, Inc., operating contractor 
at Cornhusker Army Ammunition Plant, 
has earned a National Safety Council 
Award of Merit for its outstanding 
safety performance. From March 
through August, 1970, the Plant 
accumulated over 2,000,000 manhours 
without a disabling injury. 

Mr. J. M. Higgins, Plant Manager 
(fourth from left), is shown pre- 
senting the plaque to the Division 
Managers in recognition of their 
efforts toward achieving the award. 




26 





EXPLOSIVES SAFETY 

APE 1136, PROPELLANT WEIGHING SYSTEM 


The potential hazard related to propellant weighing 
operations has been under study for years. Some weighing 
processes involved too many people, without adequate protection, 
performing too many consecutive tasks while exposed to large 
quantities of propellant. Such methods conflict with the 
cardinal principle of explosives safety; "to limit the expo- 
sure of a minimum number of personnel, for a minimum time, to 
a minimum amount of the hazardous material". Tragic incidents 
reflecting non-compliance with this principle have occurred. 
Through the accomplishments of the Ammunition Peculiar Equipment 
(APE) Program, however, recent development of the APE 1136 Pro- 
pellant Weighing System will minimize the possibility of human 
errors in this operation. 

The new equipment combines modern technologies of electronic 
logic and fluidic control circuits with standard electrical and 
pneumatic systems to provide a safer, more efficient method for 
propellant feeding, weighing, check weighing and filling car- 
tridge cases with propellant. The APE 1136 was developed as the 
result of a request for an automatic propellant dispenser to be 
used during the renovation of fixed ammunition from 40mm through 
106mm. 



27 



The propellant weighing system and its major components 
are graphically described in Figure 1 and Photo 1. A series 
of sequential tasks, performed automatically, highlights the 
operation of the equipment. The propellant storage container 
and the weighing system are separated by a wall. Propellant 
is drawn through a vacuum line from the storage container into 
the feed hopper . 

Once the predetermined amount of propellant is received 
in the feed hopper, a valve opens allowing the propellant to 
flow into the supply hopper directly below. A fluidic probe 
controls the propellant level at this point of the operation. 

If the level is low, a signal is transmitted to the vacuum line 
valve causing it to open. When the propellant reaches the desired 
depth, the probe signal changes, thus closing the vacuum line 
valve . 

The operation continues with 
the propellant dropping into the 
surge hopper , beneath which are 
two feed chutes with pans extending 
over the net weighing scale bucket. 
These chutes (see Photo 2), which 
deliver propellant from the surge 
hopper to the net weighing scale, 
are electronically controlled by the 
net weigh apparatus. The fast feed 
chute carries the approximate charge 
weight of propellant to the net 
weighing scale; the slow feed chute 
provides smaller amoun;ts for pre- 
cision adjustment. 

When the net weighing scale is full, a solenoid opens a 
pneumatic valve, allowing the propellant to flow into the check 
weighing scale. The propellant is measured against preset limits. 
The weight, as indicated by lamps on the control panel, is shown 
as underweight, normal or overweight. Under and over readings 
also activate an audible alarm to alert the operator. Utilizing 
specific controls, the operator discharges the nonacceptable 
charge into a container. If, however, the check weigher indicates 
a normal weight, a conveyor automatically positions a cartridge 
case under the discharge chute and the charge is dumped. (The 
automatic indexing conveyor feature is still undergoing development. 

Propellant charge weights for fixed ammunition are dependent 
upon ballistic characteristics of the propellant lot. The accuracy 
of charges weighed by the APE 1136 is beyond reproach. A test was 



28 


conducted involving approximately 3,000 pounds of Ml propellant. 
Preset charge weights were 80.00 ounces per charge with an 
acceptable tolerance of + 0.25 ounce. Forty-one samples taken 
from the discharge chute after check-weighing were hand-weighed , 
on balance scales to verify accuracy. All (41) samples were 
within tolerance and the average sample weight was 80.0556 
ounces. 

The safety level of propellant weighing techniques has been 
upgraded through the development of the APE 1136 Propellant 
Weighing System. Noteworthy safety improvements are as follows: 

1. Through the elimination of five manual tasks, operating 
personnel requirements have been reduced substantially. The 
former weighing method required six to eight people while the 
APE 1136 needs no more than two operators. 

2. The new equipment and its layout bring about a sizable 
reduction in propellant quantities to which personnel are exposed. 

3 . Fluidic component implementation has sharply reduced 
the electrical hazard potential in this type of operation. 

Additionally, automatic deluge is to be installed since 
the subject equipment, when in use, is identified as a potential 
in-process fire hazard. 

The APE 1136 Propellant Weighing System is exemplary of the 
efforts taken to improve munitions operations. The safety 
features of the equipment and its operation, coupled with its 
overall efficiency, provide a representative picture of the 
accomplishments of the Ammunition Peculiar Equipment Program. 


29 


THE ELUSIVE SIDE OF PROGRESS 


Over the years, the image of the safety profession has 
been altered considerably. This change has been prompted 
by members of the profession trying to maintain pace with 
the world around them. The expanding state-of-the-art in 
other occupations called for corresponding advances in 
safety work. The stereotyped safety uni-specialist of years 
past has undergone functional evolution. He now is capable 
of performing a variety of safety-related tasks. And further 
demands will be placed upon him concurrent with technological 
advances . 

Has, then, the entire accident prevention field received 
a face lifting? To a great extent, the answer is "Yes". As 
noted above, safety personnel have broadened their abilities 
in order to keep hold of the reins of an ever-growing scope 
of work. In spite of the fact that we frequently recognize 
new hazards of critical potential, and take steps to eliminate 

o.r control them, one aspect of accident prevention has remained 
static, that being the accident itself and its causes. 'The 
accidents described below should be relevant to this fact. 

1. While operating a portable grinder, a machinist 
was struck in the mouth by fragments of the disintegrating 
wheel. He suffered loss of teeth and a fractured jaw. 
Investigation revealed that the wheel was improper for the 
job being performed. 

2. A worker was operating a portable grinder inside 
an M48A3 tank hull. His attire included a welder's helmet 
equipped with a clear safety lens in the inner window and color 
lens in the outer window. The outside window was in the open 
position. During the grinding operation, a peripheral break 

of the grinding wheel occurred. Fragments penetrated the 
inner window of the operator’s helmet and entered his left eye. ■ 
The wheel in question was determined to be inferior, and 
similar wheels were removed from service. 

3. A machine operator slipped on an oily floor at his 
worksite. He attempted to recover his balance; however, the 
full weight of his body being thrown on his hand resulted in 

a fractured wrist. 

4. A worker was in the process of cleaning a propellant 
mixer when he suddenly slipped on the greasy floor surface. 

The employee suffered a severe shoulder sprain. 


30 


5. While assisting in maintenance of a steam boiler, 
a worker sustained burns from steam and hot water. The valve 
of a steam line had been closed, but the line had not been 
bled. When the joint was partially disconnected, it blew 
apart with force, spraying steam and hot water onto the worker. 

6. Two maintenance employees were to check a gate 
valve on a steam line. After closing a valve at a reducing 
station on one side of the gate valve, the men opened a drain 
valve on the other side of the gate valve. Assuming, then, 
that the line had drained, the workers began to remove the 
bonnet from the gate valve. The bonnet bolts were removed with 
out incident. In an attempt to free the bonnet which was ad- 
hering to the valve body, one worker tapped it with a hammer. 
When the bonnet broke loose, steam blew out onto both men. One 
received second degree burns of the face, arms and trunk. 

7. A laborer was cleaning cardboard from a paper 
cutting machine when he inadvertently activated the cutting 
knife. He suffered traumatic amputation of the third and 
fourth fingers. 

8 . A paper cutter machine operator placed a ream of 
paper on the machine. While tamping the paper to assure uni- 
formity, he accidentally touched the clamp pedal, actuation of 
which grasped the paper into position for cutting. His right 
index finger was amputated when caught by the falling clamp. 

9. Two employees suffered disabling injuries due to 
the carelessness of one while cleaning a revolver. A bullet 
from the accidentally discharged weapon struck the hand of the 
worker performing the cleaning. After passing through his hand 
the bullet ricocheted off a desk and struck the hand of the 
other worker. 

10. An enlisted man was preparing to clean a .22 
calibre automatic pistol. He failed to clear the ammunition 
from the pistol prior to cleaning, and during the handling 
which followed, the pistol accidentally discharged. The round 
struck the EM in his stomach. 

The aforesaid accident narratives, when taken in consec- 
utive pairs; e‘.g l and 2, 3 and 4, etc., have rather obvious 
similarities. These pairs represent typical accidents recorded 
in AMC accident experience. None can be considered as unusual 
or infrequent. These incidents were described to emphasize 
the fact that many accident types and related causes are in a 


31 


continuous state of recurrence. Chronologically speaking, 
the even-numbered accidents occurred during FY 1970 and 
FY 1971 while the odd-numbered accidents were recorded as 
part of FY 1943 Ordnance Corps experience. Although new work 
environments with challenging new hazards are created daily, 
accident experience speaks for itself by showing that basic, 
non-spectacular accidents are still the problem of greatest 
magnitude in all work situations. 


REFERENCE PUBLICATIONS 


AR 95-5, C 2 Aviation - Aircraft Accident Prevention, 

10 Nov 70 Investigation and Reporting 


AR 385-40, C 2 Safety - Accident Reporting and Records 

24 Nov 70 

DA Cir 40-71 Medical Services - Prevention of Cold Injury 

13 Jan 71 


DA Cir 385-26 Safety - Zero in on Federal Safety 

16 Mar 71 


TB 385-101 
6 Jan 71 


Safe Use of Cranes, Crane Shovels, Draglines 
and Similar Equipment Near Electric Power 
Lines 


AMCR 70-5 Research and Development - In-Process Reviews 

27 Oct 70 


AMCR 750-14, C 1 
5 Nov 70 


Maintenance of Supplies and Equipment - Pre- 
paration and Review of Standing Operating 
Procedures (SOP's) for Ammunition Activities 


AMC Suppl #1 to 
AR 40-32 
26 Oct 70 


Medical Services - Surveillance of Cargo 
Shipments from Southeast Asia 


AMC Suppl Hi to 
AR 50-2 
22 Oct 70 


Nuclear Weapons and Materiel - Nuclear Weapon 
Accident and Incident Control (NAIC) 


(Continued on page 33 ). 


32 


US ARMY ARMOR AND ENGINEER BOARD 
RECEIVES AMC AWARD OF MERIT FOR SAFETY 



The US Army Armor and 
Engineer Board has earned an 
AMC Award of Merit for Safety 
in recognition of outstanding 
safety performance during FY 1970. 

MG Frank M. Izenour, Commanding 
General, US Army Test and Evaluation 
Command, is shown presenting the 
award to COL Albert H. Hislop, 
President, US Army Armor and Engineer 
Board . 


JEFFERSON PROVING GROUND WINS AMC 
AWARD OF HONOR FOR SAFETY 


MG Frank M. Izenour, Commanding 
General, US Army Test and Eval- 
uation Command, is shown presenting 
an AMC Award of Honor for Safety, 

FY 1970, to COL John 0. Mayhall, 
Commanding Officer, Jefferson 
Proving Ground. This marks the 
third consecutive year, and fifth 
of the last seven, that Jefferson 
Proving Ground has received the 
highest recognition for safety 
performance of the installations 
and activities under USATECOM. 



V* •;« *’« 

4% 


REFERENCE PUBLICATIONS (Continued from page 3 2 ) 


AMC Suppl #2 to 
AR 50-21 
18 Nov 70 


Chemical and Biological Surety 
Program - Chemical-Biological 
Accident and Incident Control (CBAIC) 


AMC Suppl #1 to 
AR 70-10 

18 Aug 70 


Research and Development - Test and 
Evaluation During Research and 
Development of Materiel 


33 




DID YOU TAKE A GOOD LOOK 
IN YOUR MIRROR TODAY? 

Did you see a person there you can trust and respect safetywise? 
Or, did you see a person who commits errors and sets up unsafe 
conditions? Thus creating events that could lead to accidents. 

Think for a moment about the image you observed today. Is there 
a need to change that image? You be the judge after you have 
read this article. 

To help you decide, you must first know the technical definition 
of the word SAFETY, which is twofold. 

1. Freedom from those conditions that can cause injury or death 
to personnel, damage to or loss of equipment or property. 

2. Freedom from those circumstances (hazards) which can cause 
damage to or loss of personnel, products or property. 

Here is where you fit into the big picture. Unless you, as an 
individual, continuously practice accident prevention, then we 
are vulnerable to accident situations. A responsive person must 
understand that mistakes or errors involving humans and machines 
can and do cause accidents. 

In our operations here at the Plant, human errors, such as opera- 
tional mistakes involving faulty judgements, incomplete actions, 
short cuts, procedural deviations, miscalculations and just plain 
stupidity, were causative factors in past accidents. These same 
errors are also associated with everyday off-the-job home acci- 
dents . 

Our Standing Operating Procedures, Safety Standards and other 
directives are designed as the basic ground rules for accident 
prevention; but, to be totally effective, 1007o compliance by all 
employees is mandatory if we are to assure error-free, accident- 
free performances. When each employee functions properly, con- 
siders all Safety Factors associated with the specific job being 
performed, and performs with skill and proficiency, then Safety 
can be successfully integrated in daily operations. Remember, 
accident prevention rules, whether they be local, plant, state or 
federal rules, are primarily designed for our protection and 
welfare . 

Tomorrow, take another good look in a mirror and let 'Is hope you 
see a person dedicated to error-free performance henceforth. 


Mason & Hanger-Silas Mason Co., Inc. 
Cornhusker Army Ammunition Plant 


34 



Here are ten questions that will test your knowledge 
of safety requirements that you will need under different 
circumstances. Answers to these questions may be found in 
the AMCR 385-series and the AMC Supplements to the AR 385-series. 
How many can you answer without referring to the regulations? 

1. A one-room explosives operating building has 19 employees. 

What is the minimum number of exits required? 

Answer and reference: 

2. Should repairs to nuclear weapon containers be performed in 
magazines ? 

Answer and reference: 

3 . What is the minimum following distance required for material 
handling trucks? 

Answer and reference: 

4. What electrical requirements must be met by laser facilities? 

Answer and reference: 

5. Is there any significant difference between white phosphorus 
and plasticized phosphorus which might cause safety consideration? 

Answer and reference: 

6. What term is used to describe the self-ignition of certain 
fuels and oxidizers upon their contact with each other? 

Answer and reference: 


35 


7. What first-aid methods are to be administered to personnel 
having been exposed to chemical agent CS in aerosolized form? 

Answer and reference: 

8. What class of hazardous location would a butane atmosphere 
be considered? 

Answer and reference: 

9. Identify an acceptable guide for .programming office safety. 
Answer and reference: 

10. DA Form 2398 is used by each AMC command, installation and 
activity to summarize accident exposure. What is the distribution 
for this report? 

Answer and reference: 


MOBILITY EQUIPMENT R&D CENTER WINS 
NATIONAL SAFETY COUNCIL AWARD OF HONOR 



The US Army Mobility Equipment R&D Center (MERDC) , Fort 
Belvoir, was recently presented a National Safety Council Award 
of Honor for having accumulated more than 3,000,000 injury-free 
manhours. Shown at award presentation ceremonies in the above 
photograph are (left to right) Mr. John Kordalski, Safety 
Engineer, and COL Bennet L. Lewis, Commanding Officer, MERDC; 
and BG George M. Bush, Commanding General, US Army Mobility 
Equipment Command. 


36 


LIMA ARMY MODIFICATION CENTER WINS 
SEVENTH CONSECUTIVE AMC AWARD MERIT 



Lima Army Modification Center 
earned its seventh consecutive AMC 
Award of Merit for Safety in FY 1970. 
Shown at the presentation ceremonies 
are BG Alvin C. Isaacs, Deputy Commanding 
General, US Army Tank-Automotive 
Command; CAP Kenneth R. Grice, Commanding 
Officer, Lima Army Modification 
Center; Mr. R. J. Burger, Safety 
Officer; and Mr. R. J. Shirock, 

Safety Director, US Army Tank- 
Automotive Command. 


DANGEROUS CHEMICAL REACTIONS 


Safety Management Newsletter 
Hq, Airforce Systems Command 


Flashlight batteries are usually 
made of graphite and zinc. Electricity 
is generated by chemical reaction 
between the zinc and graphic. The 
same "battery" can be created on you.r- air- 
craft if you write on aluminum with 
your graphite pencil. In one case, an 
inspector drew a pencil line around a 
crack in an aluminum wing skin. Two 
months later the crack wasn’t a problem 
because the entire disc fell out. The 
pencil mark acted as a perfect can opener. 
Instead of graphite pencils, carry a 
grease pencil and use it properly. 



J. H. Cates, SMAMA 
McClellan AFB , CA 


37 



Here are the answers to the questions on pages 3 5 and 3 6 • 

A reference to the pertinent regulation and paragraph follows 
each answer. 

1. A minimum of five exits is required for an explosives 
operating building with 19 employees. Two exits are required 
for eight employees, and one additional exit is necessary for 
each five additional employees or portion thereof. Reference: 
Paragraph 5-7, AMCR 385-100. 

2 . Repairs to nuclear weapon containers in magazines shall not 

be considered as normal. In the event that minor repair is 
required, the repair will be restricted to component replacement 
which does not require cutting, drilling, soldering, welding or 
other operations producing heat or flame. Reference: Paragraph 

3-9 j , AMCR 385-100 . 

3. A distance of at least three truck lengths shall be maintained 

between trucks in operation. Reference: Paragraph 24-lla, 

AMCR 385-100. 

4. Electrical equipment and wiring for laser facilities will 

comply with the requirements of the latest edition of the National 
Electrical Code. In cases where explosives or hazardous atmos- 
pheres are involved, the equipment and wiring requirements of 
AMCR 385-100 are mandatory. Reference: Paragraph 4, Appendix A, 

AMCR 385-29. 

5. Yes. White phosphorus ignites and burns quicker than does 

the plasticized compound. Reference: Paragraph 5, Section I, 

AMCR 385-103. 

6. The term "hypergolic" describes the self -ignition upon contact 

of fuel and oxidizer. Reference: Paragraphs 2-38 and 15-2, 

^MCR 385-100. 


ii 


38 


7 . Personnel exposed to agent CS in aerosolized form shall 
receive first-aid treatment as follows: 

a. Personnel will be removed immediately to an uncontaminated 
atmosphere . 

b. If agent has gotten into the eyes, the eyes shall be 
thoroughly flushed with clean water. The eyes must not be 
rubbed . 


c. If recovery is not prompt, the person shall be taken to 
a medical doctor for further treatment. Eye ointment or other 
types of medication will be used only when prescribed by a 
physician . 

Reference: Paragraphs 13a(l), (2) and (3), AMCR 385-104. 

8. An atmosphere containing butane is considered to be a Class 1, 

Group D location. Reference: Paragraph 6-3f(3)*4, AMCR 385-100 . 

9. Safe Practices Pamphlet No. 108, Office Safety, National 

Safety Council, is acceptable as a guide for programming office 
safety. Reference: Paragraph 9-38c, AMCR 385-100. 

10. Reporting commands, installations and activities will forward 

the original DA Form 2398 direct to the Director, AMC Field Safety 
Agency, to arrive not later than the 5th calendar day of the 
month following the month for which accident exposure is being 
reported. Reference: Paragraph 2a, Routing Column, Appendix H, 

USAMC Supplement 1 to AR 385-40. 


39 


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WASHINGTON, D.C. 20315